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(b) Commercial (Including Medicaid and Exchange, if applicable) <br />(c) Medicare Part D Covered Vaccine Claims: Medicare Part D Vaccine Claims shall adjudicate at the <br />lower of U&C or the amounts shown in the table below. <br />P; p: Participating <br />Member Submitted <br />Vaccine Claims <br />Pharmacy ALL OTHER <br />Vaccine Claims <br />Vaccine Claims <br />INFLUENZA VACCINES <br />Pass -Through Pass -Through <br />(excluding foreign claims) <br />Vaccine <br />Administration <br />(capped at $15 per (capped at $20 per <br />amount <br />Fee <br />vaccine claim vaccine claim)Submitted <br />Physicians <br />Ingredient Cost <br />Participating Pharmacy Participating Pharmacy <br />Lower of submitted <br />Ingredient Cost as set Ingredient Cost as set <br />Submitted amount <br />amount or pharmacy <br />forth in the Agreement forth in the Agreement <br />Fee <br />Dispensing Fee <br />Participating Pharmacy Participating Pharmacy <br />(capped at $20 per <br />Dispensing Fee as set Dispensing Fee as set <br />Submitted amount <br />Vaccine Claim) <br />forth in the Agreement forth in the Agreement <br />Administrative <br />Administrative Fee per Prescription Drug Claim as <br />Administrative Fee per <br />Fee/Vaccine <br />set forth in the Agreement <br />Prescription Drug Claim <br />Claim <br />Pass -Through <br />(plus manual claim <br />Pass -Through <br />administrative fee) as set <br />contracted rate <br />forth in the Agreement <br />Vaccine Program <br />$2.50 per vaccine claim <br />N/A <br />Fee <br />Pass -Through <br />amount or pharmacy <br />(c) Medicare Part D Covered Vaccine Claims: Medicare Part D Vaccine Claims shall adjudicate at the <br />lower of U&C or the amounts shown in the table below. <br />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY AND <br />CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS <br />Participatin- <br />Member Submitted <br />Vaccine Claims <br />Pharmacies/ESIcies/ESI Mail <br />Vaccine Claims <br />Submitted <br />Pharmacy/ESI Specialty <br />(excluding foreign <br />Electronically .q <br />Pharmacy <br />claims) <br />Physicians <br />Vaccine <br />Lower of submitted <br />Administration <br />Pass -Through <br />amount or pharmacy <br />Pass -Through <br />Fee <br />(capped at $20 per Vaccine <br />contracted rate (capped at <br />(capped at $20 per <br />Claim) <br />$20.00 if administered at a <br />Vaccine Claim) <br />Partici at ng Pharmacy) <br />Ingredient Cost <br />Lower of submitted <br />Pass -Through <br />amount or pharmacy <br />Pass -Through <br />contracted rate <br />Dispensing Fee <br />Lower of submitted <br />Pass -Through <br />amount or pharmacy <br />Pass -Through <br />contracted rate <br />Vendor <br />Pass through at ESI cost <br />Transaction Fee <br />N/A <br />N/A <br />for Vendor Transaction <br />Fee (currently $3.75, <br />subject to change) <br />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY AND <br />CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS <br />